President-elect Trump doesn’t have much to say about public health, but he has been clear about health care. No matter how you slice his health care reform plan, the 75,240 Mainers currently benefiting from Obamacare will lose coverage if he carries out his campaign promise to repeal the Affordable Care Act.
Health care reform
Mr. Trump made few concrete statements about public health over the course of his campaign. His policy positions related to health focused primarily on health care reform. Public health is not the same as health care; however ensuring access to health care services is one important function of the public health profession, so sensible health care reform is at the top of the list of public health priorities.
Here’s what we can piece together based on Mr. Trump’s public comments and formal policy statements. Mr. Trump said on numerous occasions during the campaign that he would repeal the Affordable Care Act (ACA) on his first day in office, but since being elected, he has softened that position somewhat. In an interview with 60 Minutes, Mr. Trump stated clearly that he would maintain the aspects of the law that require insurers to cover people with pre-existing conditions, as well as those that allow children to remain on their parents’ health insurance until age 26.
He went on to say he would “repeal and replace” the ACA with a better and cheaper system. So far, the specifics of that system appear to include a new individual tax deduction for health insurance premiums, permitting health insurance carriers to sell insurance across state lines, and a Medicaid overhaul. According to The Commonwealth Fund, the combined effect of these reforms will likely mean a decrease in the number of people with health insurance.
Mr. Trump’s proposed changes to Medicaid include repealing Medicaid expansion and providing states with block grants to administer Medicaid funds. Funding through block grants is not a new idea, and there are certainly merits to a system that provides greater flexibility to states. In Maine, however, that would likely not increase access to health care.
In the current political environment, where Maine policy makers have failed to implement Medicaid expansion and changes in MaineCare eligibility have significantly reduced the number of MaineCare members, it is unlikely that shifting to a block grant system for Medicaid would help many Mainers.
Donald Trump and Science
Science and evidence drive effective public health policy. President-elect Trump seems to have an understanding of the importance of innovation and research to a healthy economy, though his commitment to science is less impressive.
The Scientific American rated the 2016 presidential candidates on their approaches to “the scientific endeavor.” Here’s part of their summary of Mr. Trump’s take on public health:
[Mr.] Trump suggests that “in a time of limited resources,” public health spending may not provide “the greatest bang for the buck.” In fact, studies show that public health efforts typically offer returns on investment of between 125 percent and 3,900 percent, depending on the program. Trump offers no indication that he has grappled with the issue in any detail.
The Scientific American gave Mr. Trump a grade of 0/5 for his scientific approach to public health.
Other Policy Positions
President-elect Trump’s opposition to abortion, his comments on vaccines (“not helpful”), his seeming disbelief in the scientific explanations for climate change, and his discriminatory and shocking remarks about women and minorities raise huge concerns for public health professionals and health care providers alike. In fact, some physicians have declared him a threat to health.
Economic opportunity, in the form of well-paying jobs, can have a significant impact on the health of the population. If the President’s policies lead to economic development, including his proposed investments in domestic infrastructure and tax reform, there is potential for improvement of the public’s health. That said, if economic benefits are unevenly distributed or are offset by poor public health policies, there would likely be no positive impact on public health.
To the extent that there is an appetite for continuing any of President Obama’s policies, the Trump administration might consider the Pay for Success initiative, which links private funding with public services such as early childhood education to deliver better outcomes at lower cost.
The LePage Connection
Public health professionals in Maine are right to be concerned about the Trump presidency. We are used to “doing more with less” under the LePage administration, and this situation is likely to continue.
What will our governor’s support for Mr. Trump mean for Maine? We’ve already heard Governor LePage say he’s going to talk to Mr. Trump about legalizing recreational use of marijuana, and about possibly delaying implementation of the referendum which is presumed to have passed. What about a position for Governor LePage in the Trump administration? That’s anybody’s guess.
Right now, we are heading into a period of deep uncertainty. We need to work together to create and maintain public-private partnerships to retain as much support for public health as we can, rely on philanthropic groups to protect vulnerable populations as best we can, maintain support among decision-makers at the state and local levels, and plan for a future when public opinion hands us elected officials with a greater interest in public health.
The Bottom Line
What does the Trump presidency mean for public health in Maine? Honestly, no one knows.